Provider Demographics
NPI:1699796441
Name:TAKIFF, JEROME WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:WILLIAM
Last Name:TAKIFF
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790
Mailing Address - Country:US
Mailing Address - Phone:860-489-1291
Mailing Address - Fax:860-489-1804
Practice Address - Street 1:895 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790
Practice Address - Country:US
Practice Address - Phone:860-489-1291
Practice Address - Fax:860-489-1804
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT21436207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004394904Medicaid
C01177OtherMEDICARE GROUP UPIN
CT004394904Medicaid
110000949Medicare ID - Type Unspecified